Impact of Sepsis Flow Chip, a novelty fast microbiology method, in the treatment of bacteremia caused by Gram-negative bacilli

Objective

The aim of this study was to assess the impact of the information provided by the new Sepsis Chip Flow system (SFC) and other fast microbiological techniques on the selection of the appropriate antimicrobial treatment by the clinical researchers of an antimicrobial stewardship team.

Methods

Two experienced clinical researchers performed the theoretical exercise of independently selecting the treatment for patients diagnosed by bacteremia due to bacilli gram negative (BGN). At first, the clinicians had only available the clinical characteristics of 74 real patients. Sequentially, information regarding the Gram stain, MALDI-TOF, and SFC from Vitro were provided. Initially, the researchers prescribed an antimicrobial therapy based on the clinical data, later these data were complementing with information from microbiological techniques, and the clinicians made their decisions again.

Results

The data provided by the Gram stain reduced the number of patients prescribed with combined treatments (for clinician 1, from 23 to 7, and for clinician 2, from 28 to 12), but the use of carbapenems remained constant. In line with this, the data obtained by the MALDI-TOF also decreased the combined treatment, and the use of carbapenems remained unchanged. By contrast, the data on antimicrobial resistance provided by the SFC reduced the carbapenems treatment.

Conclusions

From the theoretical model the Gram stain and the MALDI-TOF results achieved a reduction in the combined treatment. However, the new system tested (SFC), due to the resistance mechanism data provided, not only reduced the combined treatment, it also decreased the prescription of the carbapenems.

A versatile microfluidic platform measures hyphal interactions between Fusarium graminearum and Clonostachys rosea in real-time

Routinely, fungal-fungal interactions (FFI) are studied on agar surfaces. However, this format restricts high-resolution dynamic imaging. To gain experimental access to FFI at the hyphal level in real-time, we developed a microfluidic platform, a FFI device. This device utilises microchannel geometry to enhance the visibility of hyphal growth and provides control channels to allow comparisons between localised and systemic effects. We demonstrate its function by investigating the FFI between the biological control agent (BCA) Clonostachys rosea and the plant pathogen Fusarium graminearum. Microscope image analyses confirm the inhibitory effect of the necrotrophic BCA and we show that a loss of fluorescence in parasitised hyphae of GFP-tagged F. graminearum coincides with the detection of GFP in mycelium of C. rosea. The versatility of our device to operate under both water-saturated and nutrient-rich as well as dry and nutrient-deficient conditions, coupled with its spatio-temporal output, opens new opportunities to study relationships between fungi.

[How to organize a Fetal Medicine Unit in the context of COVID-19 pandemic. Safe measures for obstetric scans and equipment cleaning]

During a pandemic, the three basic principles are. to prioritize medical resources, ensure patients' lockdown in order to avoid community transmission and prevent healthcare collapse, and keep the number of visits to an absolute minimum to avoid patient exposure and safeguard healthcare workers. Antenatal care must be maintained during a health crisis, regardless of the COVID-19 state of alert. Routine and specialist obstetric ultrasound scans are essential for clinical decision-making during pregnancy, as it has a direct impact on the management of mothers and fetuses and on the perinatal outcome. In an attempt to minimize in-person visits, these will be organized according to the established ultrasound schedule. Based on scientific evidence, and on existing main national and international guidelines, this document has been prepared, in which proposals and options are provided for managing pregnant women in the context of the SARS-CoV-2 pandemic. It includes how a Fetal Medicine Unit facing this health crisis should be restructured, what safety measures should be followed in the performance of obstetric scans and invasive procedures, and how ultrasound rooms, equipment and transducers should be cleaned and disinfected. These recommendations should be adapted to different units based on their resources and infrastructure.

Overcoming multimorbidity: Chrodis Integrated Multimorbidity Care Model pilot implementation

Background

Multimorbidity (MM) has become one of the greatest challenges for patients and healthcare providers, calling for the development of care models that offer holistic, patient-centered care plans. Our objective was to assess the applicability and effectiveness of the Chrodis Integrated Multimorbidity Care Model (IMCM) to improve care for patients with MM in the Public Health System of Aragón, a region in northeastern Spain where MM affects 80% of people over 65 years of age.

Methods

We developed and implemented a set of actions (”change package”) to target three main improvement areas (i.e., care fragmentation, training of professionals and community care) covering all five dimensions of the model. We used key process and outcome indicators to evaluate each action, including healthcare service use (hospitalizations, emergency room visits), delivery of care (care plans, case managers), improvement in MM management skills of professionals (online training course), and patient self-perceived quality of care (ad-hoc questionnaire).

Results

291 patients of over 65 years of age with MM were recruited. At the end of the implementation every patient had a designated case manager and an individualized care plan, and 96.7% had their social situation assessed. During the 1-year pilot intervention, patients averaged 0.69 hospitalizations and 1.24 visits to the emergency room; 87.5% reported a self-perceived improvement of received care. 348 community resources were mapped and made available online in an official website. 89% of professionals who were offered to participate in the training programme agreed, reporting 8.3/10 satisfaction with the course, and improved their MM management skills from 7.36 to 9.18/10.

Conclusions

The IMCM is applicable in the context of the Spanish Public Health System and is effective in improving quality of care for patients and professionals alike.

Key messages

Reinforcing the mechanisms that integrate community, primary and hospital care is still necessary if we intend to reduce the negative health outcomes associated to care fragmentation in multimorbidity. The sustainability of the model requires the continued collaboration of key stakeholders and the awareness that multimorbidity is an issue that exceeds purely economic and structural barriers.

Etiology of bloodstream infections at a population level during 2013-2017 in the Autonomous Community of Valencia, Spain

Introduction

Bloodstream Infections has become in one of the priorities for the antimicrobial stewardship teams due to their high mortality and morbidity rates. Usually, the first antibiotic treatment for this pathology must be empirical, without microbiology data about the microorganism involved. For this reason, the population studies about the etiology of bacteremia are a key factor to improve the selection of the empirical treatment, because they describe the main microorganisms associated to this pathology in each area, and this data could facilitate the selection of correct antibiotic therapy.

Material and methods

This study describes the etiology of bloodstream infections in the Southeast of Spain. The etiology of bacteremia was analysed by a retrospective review of all age-ranged patients from every public hospital in the Autonomous Community of Valencia (approximately 5,000,000 inhabitants) for five years.

Results

A total of 92,097 isolates were obtained, 44.5% of them were coagulase-negative staphylococci. Enterobacteriales was the most prevalent group and an increase in frequency was observed along the time. Streptococcus spp. were the second microorganisms more frequently isolated. Next, the most prevalent were Staphylococcus aureus and Enterococcus spp., both with a stable incidence along the study. Finally, Pseudomonas aeruginosa was the fifth microorganism more frequently isolated.

Conclusions

These data constitute a useful tool that can help in the choice of empirical treatment for bloodstream infections, since the knowledge of local epidemiology is key to prescribe a fast and appropriate antibiotic therapy, aspect capital to improve survival.

From laboratory to the field: biological control of Fusarium graminearum on infected maize crop residues

Aim

To evaluate biological control agents (BCAs) against Fusarium graminearum on infected maize stalks as a means to reduce Fusarium head blight (FHB) in subsequently grown wheat.

Methods and Results

In the laboratory, BCAs were applied against F. graminearum on maize stalk pieces. Clonostachys rosea inhibited the perithecia development and ascospore discharge when applied before, simultaneously with and after the pathogen. In the field, we simulated a system with high disease pressure, that is, a maize‐wheat rotation under no‐tillage, by preparing maize stalks inoculated with F. graminearum. The infected stalks were treated with formulations of C. rosea selected in vitro or the commercial BCA strain Trichoderma atrobrunneum ITEM908 and exposed to field conditions over winter and spring between winter wheat rows. Monitoring with spore traps and of FHB symptoms, as well as quantification of F. graminearum incidence and DNA in harvested grain revealed significant reductions by C. rosea by up to 85, 91, 69 and 95% compared with an inoculated but untreated positive control, respectively. Deoxynivalenol (DON) and zearalenone (ZEN) contents were reduced by up to 93 and 98%, respectively. Treatments with T. atrobrunneum were inconsistent, with significant reductions of DON and ZEN under warm and wet climatic conditions only.

Conclusions

The findings support the application of C. rosea against F. graminearum on residues of maize to suppress the primary inoculum of FHB.

Significance and Impact of the Study

As sustainable agriculture requires solutions to control FHB, hence, the application of C. rosea during the mulching of maize crop residues should be evaluated in on‐farm experiments.

TaqMan qPCR for Quantification of Clonostachys rosea Used as a Biological Control Agent Against Fusarium graminearum

Clonostachys rosea is a biological control agent against Fusarium graminearum in small grain cereals and maize. Infections with F. graminearum do not only reduce the yield but, due to the production of mycotoxins, also affect the entire value chain of food and feed. In addition, production of other secondary metabolites such as hydrophobins, also known as gushing inducers, may cause quality challenges for the malting and brewing industry. Sustainable disease control strategies using C. rosea are treatment of infected residues of the previous crop, direct treatment of the actual cereal crop or post-harvest treatment during malting processes. Follow-up of growth and survival of biocontrol organisms during these different stages is of crucial importance. In the current study, we developed a quantitative real-time PCR detection method that amends the currently available culture-dependent techniques by using TaqMan chemistry with a highly specific primer and probe set, targeting the actin gene. We established a sensitive assay that detects the biological control agent down to 100 genome copies per reaction, with PCR efficiencies between 90 and 100%. The specificity of the assay was confirmed against a panel of 30 fungal and 3 bacterial species including 12 members of the Fusarium head blight complex and DNA of barley, maize and wheat. The DNA of C. rosea was detected in Fusarium-infected maize crop residues that were either treated in the laboratory or in the field with C. rosea and followed its DNA throughout the barley malting process to estimate its growth during grain germination. We used a standardized DNA extraction protocol and showed that C. rosea can be quantified in different sample matrices. This method will enable the monitoring of C. rosea during experiments studying the biological control of F. graminearum on cereal crop residues and on cereal grains and will thus contribute to the development of a new disease control strategy.

Abstract P6-18-17: Ribociclib + letrozole in patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–) advanced breast cancer (aBC) with no prior endocrine therapy (ET) for ABC: CompLEEment-1 trial, preliminary results from Spanish population

Background: The phase III Monaleesa-2, Monaleesa-3 and Monaleesa-7 trials have shown significantly improved PFS for the combination ribociclib + ET vs ET + placebo in pre-, peri-, and postmenopausal women with HR+/HER2–, first and second line aBC. The Compleement-1 trial is a phase IIIb, single-arm, open-label, international study to assess the safety and efficacy of ribociclib + letrozole in men and women who have not received prior ET for HR+, HER2– ABC [J Clin Oncol 36, 2018 (suppl; abstr 1056)].

Methods: 526 patients with HR+, HER2– ABC, ≤1 line of prior CT, and no prior ET for aBC were enrolled in the Compleement-1trial in Spain from April 2017 to January 2018. Patients received ribociclib (600 mg/day, 3 weeks on/1 week off) + letrozole (2.5 mg/day); men and premenopausal women received concomitant goserelin (3.6 mg subcutaneous implant every 28 days). The primary objective was safety and tolerability. Here we report on a sub-analysis from the Spanish population of Compleement-1 trial including baseline characteristics and early safety results for the first patients enrolled who completed at least 56 days of follow-up or discontinued before the cut-off date (3rd Oct 2017).

Results: One hundred fifty four patients constituted the analytical cohort for this sub-analysis. Demographics and baseline characteristics: median age was 52 years (range 24-82); 1% of patients were male, 31.8% female pre-menopausal and 67.5% female post-menopausal; 44.2% vs 38.3% of patients had visceral disease vs bone only disease; 49.9% patients had ≥2 metastatic sites; and 34.4% of patients presented as de novo stage IV. The median exposure for study treatment was 1.8 months (range 0.8-1.8). The grade 3/4 events reported >1% included neutropenia (50%), increased GGT levels (3.2%), leukopenia (1.3%), and increased ALT (1.3%). QTcF prolongation >480ms based on ECG data was reported in 1.2% patients. Median dose intensity for ribociclib was 600mg/day (range 476.5-600); 11% of patients required one dose reduction (8.4% due to AEs), 59.7% had at least one dose interruption (57.1% due to AEs) and 9.7% were permanently discontinued (4.5% due to AEs).

Conclusions: Preliminary safety results from this Compleement-1 sub-analysis including Spanish population are consistent with previous data presented from Monaleesa-2, Monaleesa-3, Monaleesa-7 and Compleement-1. These data support the predictable and manageable safety profile of ribociclib in combination with letrozole. Clinical trial information: NCT02941926

Citation Format: Salvador J, Ciruelos EM, Prat A, Jiménez-Rodríguez B, de la Cruz L, Martínez N, Villanueva Vázquez R, de Toro R, Antón A, Moreno F, Alvarez I, Gavila J, Quiroga V, Vicente E, de la Haba J, González-Santiago S, Díaz N, Barnadas A, Cantos Sánchez de Ibargüen B, Delgado JI, Bellet M, Gimeno A, Sanz S, Martin M. Ribociclib + letrozole in patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–) advanced breast cancer (aBC) with no prior endocrine therapy (ET) for ABC: CompLEEment-1 trial, preliminary results from Spanish population [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-17.

Effects of the citrus flavonoid extract Bioflavex or its pure components on rumen fermentation of intensively reared beef steers

Two experiments were performed to study the effects of the citrus flavonoid extract Bioflavex (BF; Interquim SA, FerrerHealthTech, Sant Cugat, Barcelona, Spain) or its components on the rumen fermentation of a high-concentrate diet. In an in vivo experiment, eight Friesian steers (398 ± 12.2 kg bodyweight) fitted with a rumen cannula were given a basal concentrate (CTR) or a CTR supplemented with BF (450 mg/kg dry matter, DM) in a 2 × 4 crossover design. No differences were observed in performance parameters of BF and CTR steers. Diet BF increased pH values and the molar proportion of propionate and reduced lactate concentration as a result of an increase in the relative abundance of lactate-consuming microorganism Selenomomas ruminantium (P < 0.01) and Megaesphaera elsdenii (P = 0.06). In an in vitro experiment, the effect of BF and its pure flavonoid components added to the incubation medium was studied separately. Bioflavex and its main components naringine, neohesperidine (NH) and poncirine (PC) were added to the incubation medium at 500 µg/g DM, with the unsupplemented substrate also included as a control (CTR). After 12 h of incubation, flavonoid mixture and NH and PC reduced (P < 0.01) the volume of gas produced and the molar proportion of acetate (P < 0.01), and increased that of propionate (P < 0.01). PC reduced the relative quantification of Streptococcus bovis, whereas NH and BF increased the relative quantification of M. elsdenii in relation to CTR (P < 0.01). Bioflavex supplementation in steers in feedlot was effective in preventing a collapse in pH and it enhanced rumen fermentation efficiency through modifying the activity of lactate-consuming bacteria and a greater molar proportion of propionate and a reduction of that of acetate, suggesting its positive role in modulating the activity of rumen microbiota.

Impact of a stewardship program on bacteraemia in adult inpatients

OBJECTIVE

Bloodstream infections (BSIs) are associated with considerable morbidity and mortality among inpatients. The aim of this study was to evaluate the impact of a stewardship program on clinical and antimicrobial therapy-related outcomes in patients with bacteraemia.

METHODS

Single-centre, before-and-after quasi-experimental study in adult inpatients. Over 1 January 2013 to 31 June 2013 all patients aged 18 years or older with a bacteraemia (interven-tion group, N=200) were compared to a historical cohort (1 Janu-ary 2012 to 31 December 2012) (control group, N=200).

RESULTS

Following blood culture results and adjusting for potential confounders, the stewardship program was associated with more changes to antibiotic regimens (adjusted odds ratio [ORa]: 4.6, 95% CI 2.9, 7.4), more adjustments to antimicrobial therapy (ORa: 2.4, 95% CI 1.5, 3.8), and better source control in the first five days (ORa 1.6, 95% CI: 1.0, 2.7). In the subgroup that initially received inappropriate empiric treatment (n=138), the intervention was associated with more antibiotic changes (OR: 3.9, 95% CI: 1.8, 8.5) and a better choice of definitive antimicrobial therapy (OR 2.3 95% CI: 1.2, 4.6). There were also more antibiotic changes in the subgroups with both Gram-negative (OR: 2.8, 95% CI: 1.6, 4.9; n=217) and Gram-positive (OR: 4.6, 95% CI: 1.8, 9.9; n=135) bacteraemia among those receiving the intervention, while the Gram-positive subgroup also received more appropriate definitive antimicrobial therapy (OR: 3.9, 95% CI: 1.8, 8.8).

CONCLUSIONS

The stewardship program improved treatment of patients with bacteraemia and appropriateness of therapy.

Single shot spinal anesthesia with very low hyperbaric bupivacaine dose (3.75 mg) for hip fracture repair surgery in the elderly. A randomized, double blinded study

PURPOSE

Single shot spinal anesthesia is used worldwide for hip fracture repair surgery in the elderly. Arterial hypotension is a frequent adverse effect. We hypothesized that lowering local anesthetics dose could decrease the incidence of arterial hypotension, while maintaining quality of surgical anesthesia.

METHODS

In a randomized double blinded study, 66 patients over the age of 65 years, with hip fracture needing surgical repair, were assigned to B0.5 group 7.5mg hyperbaric bupivacaine 5mg/ml (control group), and B0.25 group 3.75mg hyperbaric bupivacaine 2.5mg/ml (study group). Sensory and motor block level, and hemodynamic parameters including blood presure, heart rate and vasopressor dose administration were registered, along with rescue anesthesia needs, the feasibility of surgery, its duration, and regression time of sensory anesthesia to T12.

RESULTS

After exclusions, 61 patients were included in the final analysis. Arterial hypotension incidence was lower in the B0.25 group (at the 5, 10, and 15min determinations), and a lower amount of vasopressor drugs was needed (mean accumulated ephedrine dose 1.6mg vs. 8.7mg in the B0.5 group, p<0.002). Sensory block regression time to T12 was shorter in the B0.25 group, mean 78.6±23.6 (95% CI 51.7-110.2)min vs. 125.5±37.9 (95% CI 101.7-169.4)min in the B0.5 group, p=0.033. All but one patient in the B0.25 group were operated on under the anesthetic procedure first intended. No rescue anesthesia was needed.

CONCLUSION

Lowering bupivacaine dose for single shot spinal anesthesia for hip fracture repair surgery in elderly patients was effective in decreasing the occurrence of arterial hypotension and vasopressor use, while intraoperative quality remained.

Effects of including olive cake in the diet on performance and rumen function of beef cattle

Beef meat in many Mediterranean countries is produced by feeding the animals with high proportions of concentrates and barley straw. In these conditions, feeding costs are high and compromise the profitability of feedlots. Mediterranean countries are also major producers of olive oil, and the processing of this product generates a large quantity of co-products with a high environmental impact. No data appear available in the literature about the effects of including olive by-products in the diet of beef cattle on animal performance. A pen-feeding study was carried out during two growing phases: from 100 to 250 kg (12 weeks), and from 250 to 450 kg (18 weeks). During the first phase 120 steers (mostly Friesian, with an average age of 129 ± 1.1 days) were distributed in six groups of 20 animals each. Two groups were assigned to one of each of the following treatments: a control compound feed based on barley, control with 10% dry matter (DM) substituted by second-extraction pitted and dehydrated olive cake, and control with 20% DM substituted by olive cake. Compound feeds of this first phase were formulated to contain 16–17% crude protein, and were offered ad libitum to the animals. Barley straw was offered as a roughage source. Animals were weighed every 3 weeks, and a digestibility trial was carried out in the middle of the period with four animals per treatment. During the second phase, compound feeds were formulated to contain 14.5–15% crude protein. Rumen fermentation was studied using six steers and the feeds employed in the second growing phase, following a crossover design with two periods. Concentrates were offered once daily allowing at least 10% refusals. Barley straw was also offered as a source of roughage. For each period of the crossover, 15 days were allowed for adaptation to the experimental diets. Samples of rumen liquid were taken at 0 (just before), 4 and 8 h after feeding. The pH, and concentrations of ammonia and volatile fatty acids were determined. Inclusion of up to 20% second-extraction pitted and dehydrated olive cake (DM basis) in the diet did not affect performance of beef steers for the whole growth period. Inclusion of those ingredients in the diet of these animals might be advisable depending on their market price.

Remediation trials for hydrocarbon-contaminated sludge from a soil washing process: evaluation of bioremediation technologies

The usual fate of highly contaminated fine products (silt-clay fractions) from soil washing plants is disposal in a dump or thermal destruction (organic contaminants), with consequent environmental impacts. Alternative treatments for these fractions with the aim of on-site reuse are needed. Therefore, the feasibility of two technologies, slurry bioremediation and landfarming, has been studied for the treatment of sludge samples with a total petroleum hydrocarbon (TPH) content of 2243 mg/kg collected from a soil washing plant. The treatability studies were performed at the laboratory and pilot-real scales. The bioslurry assays yielded a TPH reduction efficiency of 57% and 65% in 28 days at the laboratory and pilot scale, respectively. In the landfarming assays, a TPH reduction of 85% in six months was obtained at laboratory scale and 42% in three months for the bioremediation performed in the full-scale. The efficiency of these processes was evaluated by ecotoxicity assessments. The toxic effects in the initial sludge sample were very low for most measured parameters. After the remediation treatments, a decrease in toxic effects was observed in earthworm survival and in carbon mineralisation. The results showed the applicability of two well known bioremediation technologies on these residues, this being a novelty.

Incidence of microflora and of ochratoxin A in green coffee beans (Coffea arabica)

Coffee is produced in tropical countries around the Equator where climatic conditions are favourable for fungal development and mycotoxin production; however, mycotoxins do not only occur in the tropical countries. The aim was to evaluate the mycoflora and possible incidence of ochratoxin A (OTA) in 60 samples of green coffee beans from Brazil. The mycological evaluation was carried out using a conventional method and the OTA was determined using sequential phenyl silane and immunoaffinity column cleanup followed by HPLC. The detection limit was 0.2 microg kg(-1). Practically all samples (91.7%) were contaminated with moulds. The dominant fungal genus was Aspergillus, including A. niger (83.3%), A. ochraceus (53.3%) and A. flavus (25.0%). The occurrence and the levels of the genus Cladosporium (16.6%) and Penicillium (10.0%) were substantially lower than Aspergilli. Twenty samples (33.3%) of 60 were contaminated with the toxin at levels ranging from 0.2 to 7.3microg kg(-1). The average concentration was 2.38 microg kg(-1). All positive samples showed OTA levels below the limit suggested by the European Union (8 microg kg(-1)).

Quasi-simultaneous imaging/pulling analysis of single polyprotein molecules by atomic force microscopy

Most of studies in protein nanomechanics have used the atomic force microscope (AFM) in its force-measuring mode on immobilized protein repeats (polyproteins) as single-molecule markers. Here, we add imaging capabilities to a standard, state-of-the-art AFM "puller" and integrate the most powerful programs of analysis available for both AFM modes. This unique instrument allows high-resolution, quasi-simultaneous imaging/force spectroscopy in aqueous solution. We demonstrate its capabilities using polyproteins of a model system (titin I27 domain). This tool should greatly facilitate the development of a much needed universal functionalization system for AFM, one that should allow better sample control and an improved efficiency of protein immobilization.

[Anesthesia in a patient with Angelman syndrome]

We describe the perioperative treatment of a patient diagnosed with Angelman syndrome, which is usually caused by a deletion in chromosome 15. The patient showed the characteristic signs of psychomotor retardation, epilepsy, lack of speech, frequent laughter and happy demeanor, light skin, blue eyes, and blond hair, hyperactivity, and sleep disturbance. He was scheduled for multiple tooth extractions under general anesthesia. Intravenous anesthesia was induced using ketamine, propofol, and rocuronium, and was maintained with low concentrations of sevoflurane. There were no incidents during or after surgery. The chromosomal abnormality that causes Angelman syndrome is located on the same genes that control the production of gamma-aminobutyric acid-A receptors, which are activated by most intravenous and inhaled anesthetic agents. The effect of the condition on the response of these agents is unknown. The combined use of propofol, ketamine, and sevoflurane at low doses provided adequate anesthesia for this patient. Other characteristics of the syndrome that may affect the use of anesthesia in these patients are discussed.

Prediction of absolute risk of non-spinal fractures using clinical risk factors and heel quantitative ultrasound

The relationship between osteoporosis risk factors, bone quantitative ultrasound (QUS) and non-spinal fracture risk was estimated in a cohort of 5,201 postmenopausal women from Spain who were prospectively evaluated during three years. Several clinical risk factors and low heel QUS values were independently associated with non-spinal fracture risk.

INTRODUCTION

Low-trauma, non-spinal fractures are a growing source of morbidity and mortality in the elderly. The aim of the present study was to examine the association of heel quantitative ultrasound (QUS) and a series of osteoporosis and fracture risk factors, with incident low energy non-spinal fractures in a population of elderly women, and to incorporate them into fracture prediction models.

METHODS

5,201 women aged 65 or older were enrolled in a three-year cohort study. Participants completed an osteoporosis and fracture risk factors questionnaire. QUS was measured at the heel with a gel-coupled device. Cox-proportional hazard analyses were performed to evaluate the association with the first incident low-trauma non-spinal fracture.

RESULTS

Three hundred and eleven women (6.0%) sustained a total of 363 low-trauma fractures, including 133 forearm/wrist, 54 hip, 50 humerus, 37 leg and 17 pelvic fractures. For every standard deviation decrease in the quantitative ultrasound index, the adjusted hazard ratios (95% CI) for any non-vertebral, hip, forearm/wrist, and humerus fractures were 1.31 (1.15-1.49), 1.40 (1.01-1.95), 1.50 (1.19-1.89) and 1.35 (0.97-1.87), respectively. Similar results were observed with other QUS variables. The best predictive models indicated that age, a history of falls, a previous low-trauma fracture, a family history of fracture, a calcium intake from dairy products of less than 250 mg/day, and lower values of QUS parameters were independently associated with the risk of non-spinal fractures.

CONCLUSIONS

Both clinical risk factors and QUS are independent predictors of risk of fragility non-spinal fractures. A prediction algorithm using these variables was developed to estimate the absolute risk of non-spinal fractures in elderly women in Spain.

Retinoids induce MMP-9 expression through RARalpha during mammary gland remodeling

Retinoic acid (RA) is a signaling molecule in the morphogenesis of the mammary gland, modulating the expression of matrix metalloproteinases (MMPs). The aim of this paper was to study the role of RA during weaning, which consists of three events: apoptosis of the secretory cells, degradation of the extracellular matrix, and adipogenesis. CRABP II and CRBP-1 carrier proteins increased significantly during weaning compared with lactating glands but reverted to control values after the litter resuckled. The effects of RA are mediated by the nuclear receptors RARalpha, RARbeta, RARgamma, and RXRalpha, which underwent an increase in protein levels during weaning. In an attempt to elucidate the RARalpha-dependent signaling pathway, ChIP assays were performed. The results showed the binding of RARalpha to the MMP-9 promoter after 24- and 72-h weaning together with its coactivator p300; this fact could be responsible for the increase found in MMP-9 mRNA and protein levels in these conditions. Expression of related MMPs (MMP-2 and MMP-3) was also increased during weaning. Using gelatine zymography, we observed a time-dependent increase in active forms of MMP-9 and MMP-2. On the other hand, the inhibitor of MMPs, TIMP-1, was almost undetectable at 24- and 72-h weaning by Western blot. The role of retinoids in matrix remodeling is reinforced by the fact that administration of an acute dose of retinol palmitate to control lactating rats also induces MMP-9 expression. This emphasizes the importance of retinoids in vivo to regulate mammary gland involution.

[Evaluation of viral load and antigenemia as markers for relapse cytomegalovirus infection in renal transplant recipients]

Cytomegalovirus (CMV) is a pathogen, commonly found in the donors and recipients of solid organ transplantation. CMV is one of the major causes of morbidity and mortality in these patients. Relapsing episodes of CMV infection occur in 23-33% of transplant patients which is likely a reflection of incomplete suppression of viral replication following antiviral treatment with intravenous ganciclovir. We have studied CMV DNA load and antigenemia as markers for relapse of CMV infection in 49 renal transplant patients out of 68 with CMV infection who received a course of intravenous ganciclovir among 300 transplants carried out between January of 2001 and June of 2005. Viral load and antigenemia were measured in blood samples obtained before, during and at the completion of treatment. We also studied different viral load as predictors of relapse CMV infection. Twelve (24.5%) of 49 recipients developed relapsing CMV infection. The relapsing group had higher viral loads after treatment than the no relapsing group. There was no difference in antigenemia level between both groups. The viral loads before and during the treatment, the age and sex of donors and recipients, inmunosupresión, percentage of seronegative recipients with seropositive donors, duration of the therapy and the percentage of patients with heavy immunosuppression were similar in the two groups, but the incidence of acute rejection was higher in the relapsing group. We also evaluated the range of viral load after treatment which is able to trigger the relapse of CMV infection. We conclude that CMV DNA load after treatment is a useful marker for individualizing antiviral treatment of CMV infection in renal transplant recipients. Acute rejection is a risk factor to the relapsing CMV infection.

Modulation of hepatocyte growth factor plasma levels in relation to the dose of exogenous heparin administered: an experimental study in rats

INTRODUCTION

Partial liver transplantation has been consolidated to be a valid treatment option. We sought to understand the factors that modulate and may be harnessed to accelerate hepatocyte regeneration. We sought to determine the impact of heparin on m-hepatocyte growth factor (HGF) plasma concentrations.

MATERIALS AND METHODS

Sixteen rats were assigned to four groups of four animals each: group A, without heparin; group B, 600 IU/kg; group C, 1000 IU/kg, group D, 1400 IU/kg. Blood samples (0.5 mL) were obtained from each rat at baseline and at 30, 60, 120, and 240 minutes. After the samples were centrifuged to separate supernates from the cell phase they were stored at -20 degrees C in the m-HGF reagent and subsequently tested using enzyme-linked immunosorbent assay. Results were analyzed using SPSS 11.5 statistical software.

RESULTS

Among the 16 rats, one died at 110 minutes, just prior to the last extraction. The remaining rats were sacrificed. Mean weight was: 466 +/- 64.24 g with no intergroup differences (P = .149). The comparative results (using Student t test) were: baseline A(1-4) versus A(1-4) 30 minutes: P < .05; baseline A(1-4) versus A(1-4) 60 minutes: P < .05; baseline A(1-4) versus A(1-4) 120 minutes: P = .10 (NS); baseline A(1-4) versus A(1-4) 240 minutes: P = .15 (NS). No significant differences were found among group B: baseline C(1-4) versus C(1-4) 30 minutes and 60 minutes: NS; baseline C(1-4) versus C(1-4) 120 minutes: P < .001; baseline C(1-4) versus C(1-4) 240 minutes: P < .10 (NS). Finally, the results in group D were: baseline D(1-4) versus D(1-4) 30 minutes: NS; baseline D(1-4) versus D(1-4) 60 minutes and 120 minutes: P < .05; baseline D(1-4) versus D(1-4) 240 minutes: P < .0005. When we compared group A to C and D, we detected differences (albeit not when compared to B) with P values = .01. Peak values were obtained at 120 and 240 minutes (225.21 pg/mL and 221.78 pg/mL) among groups C and D.

CONCLUSION

Heparin has a positive effect to increase serum HGF concentrations among rats. The effect was dependent on the administered dose and the time elapsed.

Estimation of the aging rates of populations through the prevalence of age-related diseases

Ten prevalences of disease or functional affections due to degenerative processes that statistically show a significant age-dependent behaviour were taken as variables for a biological aging study of a population living in a district of Madrid. The cross-sectional procedure consisted in grouping the disease prevalences by age decades and calculating aging by the vector-analytical mathematical method in which the age-dependent prevalence was the result of one of the total of 10 vector components. The progressive accumulative increase of the vector distances from the origin as well as the distances among the vectors in relation to the population age was considered as biological aging. On the basis of similar mathematical models the results were compared with those obtained from other populations in which different indicators were used; the results are concurrent, but show here a greater aging acceleration than when the population was composed solely of healthy individuals. This is considered a logical consequence due to the sample composition. The presented procedure, focussed epidemiologically, can be useful in comparing aging of populations.

Simultaneous liver-kidney transplantation for adult recipients with irreversible end-stage renal disease

HYPOTHESIS

Combined liver-kidney transplantation is safe (low morbidity and acceptable mortality) and effective in patients with end-stage liver disease. Although refinements in surgical technique have resulted in better patient and allograft outcomes, the negative impact of renal insufficiency on survival in patients undergoing liver transplantation has been widely reported, although some aspects are controversial.

DESIGN

Analysis of the clinical characteristics and outcome in the management of patients undergoing combined liver-kidney transplantation. The end points were operative mortality, morbidity, and long-term survival.

SETTING

University Hospital 12 de Octubre.

PATIENTS

Between May 1986 and December 2001, 820 liver transplantations were performed. There were 16 cases (1.96%) of combined liver-kidney transplantations, which represent the sample of this study.

RESULTS

Mean +/- SD follow-up of 42.2 +/- 29 months: 6 patients died (37.5% mortality rate). There were 4 (25%) hospital deaths within 6 months following surgery and 2 after 6 months (4 sepsis, 1 refractory heart failure, and 1 recurrent hepatitis C virus disease). Univariate analysis related to mortality included age, sex, etiology, preoperative creatinine level, United Network for Organ Sharing status, Child-Pugh score, type of hepatectomy (piggyback), intraoperative blood product administration, and the presence of postoperative complications. The only 2 significant factors were the presence of postoperative complications (P = .01) and the United Network for Organ Sharing status (P = .02). Crude survival rate was 62.5%. Actuarial survival rates were 80%, 71%, and 60% at 1, 3, and 5 years, respectively.

CONCLUSION

Because end-stage renal disease is not a formal contraindication for liver transplantation, a combined liver-kidney transplantation for adults with end-stage renal disease can be done safely and effectively.

Study of the correlation between two methods used to monitor thymoglobulin therapy in renal transplantation

The aim of this study is to evaluate the correlation between the 2 methods used to monitor thymoglobulin therapy: the total lymphocyte count and the number of T cells. We have performed daily collections of peripherical blood samples from 24 renal grafts, recipients who were receiving thymoglobulin, including 14 cases for induction and 10 for acute rejection. Absolute lymphocyte and T-cell counts were measured in the 298 samples after administration of a dose of 1.25 mg/kg/d. The dose was omitted if the T-cell count had decreased to <10 cells/microL. The theoretical total lymphocyte count considered to omit dose was <100 cells/microL. A total of 137 doses were given according to T-cell count. We performed the comparison in 3 steps. First, we correlated values in the daily samples; second, we examined samples as a whole and third, assessed the percentage of discrepancy between the omission of the daily dose according to each method. There was a poor correlation between the methods according to sets of daily samples or the sets as a whole. The rate of discrepancy was 66%, including 121 of 216 decisions (P<.001). In conclusion, the results of the 2 methods of monitoring thymoglobulin therapy are different, and the total administered dose depends on the method used.

Liver transplantation and transjugular intrahepatic portosystemic shunt

OBJECTIVE

Describe the results of liver transplantation after installing Transjugular Intrahepatic Portosystemic Shunt (TIPS) and compare them with those of a control group in a comparative, longitudinal, retrospective study.

MATERIALS AND METHODS

Between April 1986 and October 2002, we performed 875 liver transplantations. Between January 1996 and October 2002, 26 transplantations were performed on TIPS carriers. This group was compared with a control cohort of 50 randomly selected patients who underwent transplantation in this period (non-TIPS carriers). Both groups were homogeneous with no significant differences between age, sex United Network for Organ Sharing (UNOS) score, Child stage, or etiology.

RESULTS

Actuarial survival rates at 1 and 3 years: TIPS group 96.15% and 89.29% versus control cohort 87.8% and 81%, respectively. In 73.9%, the TIPS was clearly effective; in 88.9%, a postoperative Doppler revealed normal flow. There were no statistically significant differences compared with time on the waiting list for transplant, duration of the operation, ischemia times, intraoperative consumption of hemoderivates, vascular or nonvascular postoperative complications, duration of stay in the intensive care unit, hospital stay, or retransplantation rate.

CONCLUSIONS

In our experience, TIPS insertion does not affect either the intraoperative or postoperative evolution and is not associated with an increased time on the liver transplant waiting list.

Co-occurrence of patulin and citrinin in Portuguese apples with rotten spots

Patulin and citrinin are mycotoxins produced by certain fungi mainly belonging to Penicillium and Aspergillus and may be detected in mouldy fruits and fruit products. The data presented here refer to the simultaneous occurrence of patulin and citrinin in 351 samples of seven different varieties of apples with small rotten areas (Casanova, Golden Delicious, Red Delicious, Reineta, Richared, Rome Beauty, Starking). A rapid multidetection thin layer chromatography (TLC) method was used. The minimum detectable concentrations of patulin and citrinin were 120-130 and 15-20 microg kg(-1) respectively. The percentage contamination with patulin only was higher (68.6%) than that with citrinin only (3.9%). Patulin and citrinin (19.6%) were also detected simultaneously. The highest mean patulin content was 80.50 mg kg(-1) for the Richared variety, but the mean level of citrinin was lower. The lowest mean contaminations of patulin were found in Rome Beauty, Red Delicious and Reineta, ranging from 3.06 to 5.37 mg kg(-1). All analysed apples varieties had low citrinin contamination, ranging from 0.32 to 0.92 mg kg(-1). These findings indicate that there may be a risk of human exposure to patulin through the consumption of juices and jams manufactured with apples with small rotten areas.

[Glutaric aciduria type I: diagnosis in adulthood and phenotypic variability]

Glutaric aciduria typo I (GA I) is an uncommon metabolic disease with autosomal recessive inheritance. It usually presents in the first years of life and frequently causes movement disorders. Only a few cases have been diagnosed in adulthood. Two siblings who were diagnosed of GA I after a course of more than 20 years are reported here. The elder brother, after 9 months of normal psychomotor development, suffered from an acute encephalopathy with generalized hypotonia and, later on, dyskinetic movements. Throughout the following years severe generalized dystonia developed. The younger brother presented at 16 months with acute encephalopathy, hypotonia and generalized choreoathetoid movements. Cranial computed tomography showed in both patients an slight enlargement of Silvian cisures and diffuse white matter hypodensities. Magnetic resonance imaging performed in the second case disclosed in addition bilateral hyperintensities in putamen and caudate nucleous. At 29 and 24 years of age, respectively, an increased urinary excretion of glutaric and 3-hydroxiglutaric acids was detected in both patients. Glutaryl-CoA deshidrogenase activity in fibroblasts was absent in both. The patients were treated with carnitine and riboflavine, with no response. The present report shows that diagnosis of GA I should be considered in adults presenting a range of movement disorders from childhood.

Long-term biliary complications after liver surgery leading to liver transplantation

Chronic biliary obstruction with repeated bouts of cholangitis adversely affects quality of life and may lead to secondary biliary cirrhosis with liver failure. We reviewed our experience with chronic biliary complications after surgical treatment of various diseases that at the end needed a liver transplantation. Twelve patients with previous biliary surgery developed secondary biliary cholangitis, secondary biliary cirrhosis, or both. Seven had surgery for liver hydatid disease by Echinococcus granulosus, another four had complicated biliary surgery unrelated to hydatid disease, and one had a history of a traffic accident with liver trauma and hepatectomy with chronic biliary fistula. The repeated cholangitis attacks and in two cases of hydatid disease the development of biliary-bronchial fistulas made these patients' lives miserable. All had had previous surgical procedures that made the transplantation procedure more difficult. Nevertheless, patient survival and graft actuarial survival after liver replacement were 75.0% and 69.2%, respectively, at 5 years.

Mechanism of free radical production in exhaustive exercise in humans and rats; role of xanthine oxidase and protection by allopurinol

Exhaustive exercise generates free radicals. However, the source of this oxidative damage remains controversial. The aim of this paper was to study further the mechanism of exercise-induced production of free radicals. Testing the hypothesis that xanthine oxidase contributes to the production of free radicals during exercise, we found not only that exercise caused an increase in blood xanthine oxidase activity in rats but also that inhibiting xanthine oxidase with allopurinol prevented exercise-induced oxidation of glutathione in both rats and in humans. Furthermore, inhibiting xanthine oxidase prevented the increases in the plasma activity of cytosolic enzymes (lactate dehydrogenase, aspartate aminotransferase, and creatine kinase) seen after exhaustive exercise. Our results provide evidence that xanthine oxidase is responsible for the free radical production and tissue damage during exhaustive exercise. These findings also suggest that mitochondria play a minor role as a source of free radicals during exhaustive physical exercise.

Xanthine oxidase is involved in exercise-induced oxidative stress in chronic obstructive pulmonary disease

In the present study, we hypothesized that exhaustive exercise in patients with chronic obstructive pulmonary disease (COPD) results in glutathione oxidation and lipid peroxidation and that xanthine oxidase (XO) contributes to free radical generation during exercise. COPD patients performed incremental cycle ergometry until exhaustion with (n = 8) or without (n = 8) prior treatment with allopurinol, an XO inhibitor. Reduced (GSH) and oxidized glutathione (GSSG) and lipid peroxides [malondialdehyde (MDA)] were measured in arterial blood. In nontreated COPD patients, maximal exercise (approximately 75 W) resulted in a significant increase in the GSSG-to-GSH ratio (4. 6 +/- 0.9% at rest vs. 9.3 +/- 1.7% after exercise). In nontreated patients, MDA increased from 0.68 +/- 0.08 nmol/ml at rest up to 1. 32 +/- 0.13 nmol/ml 60 min after cessation of exercise. In contrast, in patients treated with allopurinol, GSSG-to-GSH ratio did not increase in response to exercise (5.0 +/- 1.2% preexercise vs. 4.6 +/- 1.1% after exercise). Plasma lipid peroxide formation was also inhibited by allopurinol pretreatment (0.72 +/- 0.15 nmol/ml preexercise vs. 0.64 +/- 0.09 nmol/ml 60 min after exercise). We conclude that strenuous exercise in COPD patients results in blood glutathione oxidation and lipid peroxidation. This can be inhibited by treatment with allopurinol, indicating that XO is an important source for free radical generation during exercise in COPD.

Age-related loss of proliferative activity of human vascular smooth muscle cells in culture

This work studied the proliferation activity in cultures of vascular smooth muscle cells (SMC) from individuals of different ages. The cells derived from arteries of 12 donors of both sexes from 45 to 91 years of age. The main parameter considered was the 'proliferation rate' (cells grown per day in the different culture passages) taking into account the age of the donor. No significant relationship between age of the donor and the cell life in proliferation was found. On the contrary, the mean time of passage duration for reaching the maximum of proliferation as well as its 'efficiency' (maximum of proliferation rate registered/mean time of passage duration) show a statistically significant dependence on the age of the donor. Furthermore, the proliferation rate measured in each passage is statistically significant related to donor age. The regressions obtained show a similar negative slope (VC 4%). Considering the first five culture passages, the regression crosses the x-axis at the age of 105.6+/-11.7 years. This age in which no proliferative activity of human SMC would be expected lies near the limit of maximum life potential for human beings. Our results suggest that with advancing donor age there is an increasing number of senescent SMC either primarily transferred or appeared in the culture. Vascular SMC of individuals whose life is near the end would almost be all senescent and therefore show extremely low proliferation rates in the culture. If the proliferative activity of arterial SMC is a condition for atherogenesis, the proportion of senescent cells would be inversely related to the propensity of developing the atheroma because of the inability of these cells to divide.

Usefulness of pp65 antigenemia for the early diagnosis of cytomegalovirus disease in patients with AIDS

An observational cohort study was performed to assess the effectiveness of a cytomegalovirus antigenemia (CMV-Ag) assay designed to predict clinical CMV disease in patients with AIDS. Eighty-six HIV-infected patients with CD4+ cell counts of < 100/mm3, positive CMV IgG, and no previous CMV disease were enrolled. Thirty-eight (44%) patients had at least one positive CMV antigenemia test, ten of whom eventually developed CMV focal disease. CMV disease was diagnosed in 13 (15%) patients. The CMV antigenemia assay was positive in ten of these 13 patients. Using a cut-off value of five positive cells in every 150,000 leukocytes sampled, the CMV antigenemia assay had a positive predictive value of 89% and a negative predictive value of 94%. The median time from the first positive CMV antigenemia test to the onset of CMV disease was 102 days. CMV disease probability at 6 months in patients with a CMV antigenemia value > or = 5 was 77.8% versus 6% in patients with CMV antigenemia value < 5 (log-rank test = 48.345; P < 0.001). Several independent factors were associated with the development of CMV disease: CMV antigenemia > or = 5 cells (hazard ratio: 20.44), CD4+ count < or = 25/mm3 (HR: 3.12), and sexual transmission of HIV infection (hazard ratio, 3.15). CMV antigenemia seems to be a good predictor of CMV disease in patients with AIDS.

Regulatory effects of cytokines and cyclosporine A on peripheral blood mononuclear cells from stable multiple sclerosis patients

The proliferative response (PR) of peripheral blood mononuclear cells (PBMC) to lectins such as phytohemaglutinin (PHA), anti-CD3 monoclonal antibodies such as OKT-3 or phorbol esters such as tetradecanoyl-phorbol 13-acetate (TPA) was investigated in 18 stable multiple sclerosis (MS) patients (9 untreated and 9 treated patients) and 10 healthy controls. PBMC from untreated MS patients showed a significantly higher PR to PHA than healthy controls. The PR of PHA, anti-CD3 or TPA stimulated PBMC from treated patients was lower than that from untreated MS patients. Mitogen stimulated PBMC from untreated patients shown both increased sensitivity to the stimulatory effect of IL-2 and increased resistance to the inhibitory effect of IL-10 and IFN-alpha. The addition of IL-2 increased the PR in PHA-stimulated PBMC from untreated MS patients, but not in those from treated MS patients and healthy controls. Mitogen stimulated cells from untreated patients were more resistant to the inhibitory effect of IL-10 and IFN-alpha than PBMC from either treated MS patients or healthy controls. Cyclosporine A (CsA) inhibited the PR and the expression of activation antigens induced by PHA in PBMC from the three groups of subjects. This inhibitory effect of CsA have was enhanced by the addition of IFN-alpha.